Prescribing in wound care

TVN Team

Feb 2018

Burdon of Wound care.

• The annual NHS cost of managing wounds was estimated to be £4.5–5.1 billion, two-thirds of which is incurred in the community and the rest in secondary care. This is comparable to the annual NHS cost of managing obesity which was estimated at £5.0 billion in 2013.

• Guest JF, Ayoub N, McIlwraith T, et al

• Health economic burden that wounds impose on the National Health Service in the UK

• BMJ Open 2015;5:e009283. doi: 10.1136/bmjopen-2015-009283

Abscess 160 000 (7%) 0.0032

Burn 87 000 (4%) 0.0018

Diabetic foot ulcer 169 000 (8%) 0.0034

Leg ulcer (arterial) 9000 (<1%) 0.0002

Leg ulcer (mixed) 24 000 (1%) 0.0005

Leg ulcer (unspecified) 420 000 (19%) 0.0085

Leg ulcer (venous) 278 000 (13%) 0.0056

Open wound 240 000 (11%) 0.0048

Pressure ulcer 153 000 (7%) 0.0031

Surgical wound 253 000 (11%) 0.0051

Trauma 158 000 (7%) 0.0032

Unspecified 271 000 (12%) 0.0055

Total 2 222 000 (100%) 0.0447

2012/2013 Annual number of wounds Annual prevalence among the adult UK population

Annual number p Value

Resource Cases Controls Difference

GP visits 10 816 655 3 124 120 7 692 535 <0.001

Practice nurse visits 19 744 618 1 184 322 18 560 296 <0.001

Community nurse visits 10 932 199 75 548 10 856 651 <0.001

Specialist nurse visits 51 106 4444 46 662 <0.001

Allied healthcare visits 537 722 77 770 459 952 <0.001

Hospital outpatient visits 4 277 334 828 803 3 448 531 <0.001

Hospital admissions and day cases 1 142 104 173 315 968 788 <0.001

Ambulance services 11 110 2222 8888 ns

Accident and emergency attendances 11 110 11 110 – ns

Diagnostic tests 60 284 855 24 068 613 36 216 242 <0.001

Devices 320 938 916 48 206 108 272 732 808 <0.001

Wound care products 354 954 275 0 354 954 275 <0.001

Prescriptions for individual drugs 135 859 234 38 769 310 97 089 924 <0.001

DRESSINGS – what can go wrong?

• Dressing Adherence– incredibly painful, poor experience that a patient should never have to go through.

• Bleeding / traumatic removal

Risk assess before putting a dressing on. Look for friable skin, or putting a dry dressing on a drying wound can cause sticking

What can go wrong?

• Maceration to the wound perimeter and surround skin

• Either the dressing is not being changed frequently enough or absorbency level is wrong. Consider barrier products also.

What can go wrong? • Losing dressings in open cavities with

undermining tissue – know what you are putting in , how many and whether dissolvable or stitched products.

What can go wrong?

• No progress due to lack of assessment

• Start changing of dressings – what is the plan?

• Allergies not checked e.g latex.

• Excoriation from exudate burning skin.

• Pieces of dressings cut and put back in the packet – infection control No No

• Prescribing in pregnancy and breastfeeding e.g Iodine – No No

Not just patient factors

• Prescribing of dressings can be harmful to professionalism of prescribing e.g ordering too much stock, complex combinations and duplicate products ordered.

• Not using up products before ordering more.

• Rationale not documented.

• Mixed professional opinions of dressing choices e.g TVN, dermatology , DNs, PNs and vascular teams.

Prescribing Build Ups

By going through a box in the home

environment, it is easy to see how readily wound care items are prescribed.

Here is the contents of 1 x box itemised in the home environment.

1 x box of dressings in the home environment – added up

20 x K-soft at 44p each= £8.50

19 x Dressit at 60p ea = £11.40

19 x N-A 9.5 x 19cm, 67p ea =£12.73

6 x Kerramax care 20 x 30 ,£3.33ea = 19.98

20 x Kerramax care 20 x 22cm at £2.92 ea= £58.40

32 x Kerramax 10 x 22cm, £1.65ea =£52.80

8 x Urgotul 20 x 30, £13.65ea = £109.20

30 x Zetuvit E 20 x 40, £1.06ea = £31.80

4 x Mesorb 10 x 20, 95pea, £3.80

continued…….

Same box continued

• 3 x Clinifast 10.75cm £6.04 ea = £18.12

• 7 x Kendall AMD 15 x 15, £8.92ea = £62.44

• 2 x Irriclens, £3.42ea = £6.84

• 4 x Allevyn Adhesive £2.14ea = £8.56

• 2 x Aqueous 500g, £1.72 ea = £3.44

• 1 x Oilatum plus 500ml = £6.98

• 2 x Cavilon spray, £6.54 ea = £13.08

• 1 x Sudocream = £4.34

• 1 x Conotrane = £3.51

• 28 x Actico 10 x 6m, £3.26ea = £91.28

4 x Dermol lotion 600ml, £7.55ea = £30.20

TOTAL of 1 x BOX

£549.77

Wound care Formulary

• Must provide a comprehensive range of wound dressings to ensure that all wound aetiologies are provided for and are clinically and economically effective.

• Promotes care continuity, reduction in variation, structured wound care practice. Processes for quality and feedback and valuable data.

• Positive wound care management e.g less frequent

dressing changes with better absorbency. • Ref: Best Practice statement, development of a formulary ( Wound care alliance 2008)

• Ref:NICE guidelines. Chronic wounds:advanced wound dressing and antimicrobial dressings. March 2016

How to Decide

• Think generic e.g foams or hydrocolloid

• What is the function of the dressing type?

• Make a plan with rationale and give it adequate time to take effect.

• If debriding a wound this will be a messy process and inform your patient of this- consent.

Current practice

There is often a ‘trial and error’ approach to dressing selection, and this process can continue until the wound begins to heal.

People may then credit a particular dressing type with healing their wound.

Order of dressings 1)Primary dressing: one that touches the wound bed E.g. Wound Contact Layers or Foams.

Some can have a dual function also such as an antimicrobial foam.

2)Secondary dressing: usually used to absorb or keep the primary dressing in place. Eg. Super Absorbents TOP TIP : Avoid using primary dressings as secondary dressings as it is expensive and unnecessary

Moisture balance

TOO MUCH = bacterial growth, infection risk, maceration,

excoriation, breakdown

TOO LITTLE = adherence, stagnation, early scab formation

What is wrong with this?

What is wrong with this?

Top tips for prescribing in wound care

• Adhere to the formulary – this is designed to cover 80% of wound scenarios

• Only change dressings when clinically needed, Ensure the dressing is working hard.

• Measure wounds every 2 weeks as indicator of healing.

• Know the wear time of your dressings – most are either 7 or 14 days.

• Encourage self care and shared care with patients

Top tips 2

• Don’t change product until everything else is used up unless there is a clinical reason to do so.

• Prescribe 2 weeks supply at a time as wounds can change rapidly.

• Don’t cleanse unless necessary. • Prescribe from the emollients formulary • Use antimicrobials for 14 days unless otherwise indicated with

the exception of DACC and honey. • Do not swab wounds unnecessarily – use your nose and eyes

to confirm wound infection. • Do not put dressings on repeat (unless healing is not an

outcome)